Journal article
Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection: The STOP-CAD Study
Stroke (1970), Vol.55(4), pp.908-918
04/2024
DOI: 10.1161/STROKEAHA.123.045731
PMID: 38335240
Abstract
Small, randomized trials of patients with cervical artery dissection showed conflicting results regarding optimal stroke prevention strategies. We aimed to compare outcomes in patients with cervical artery dissection treated with antiplatelets versus anticoagulation.
This is a multicenter observational retrospective international study (16 countries, 63 sites) that included patients with cervical artery dissection without major trauma. The exposure was antithrombotic treatment type (anticoagulation versus antiplatelets), and outcomes were subsequent ischemic stroke and major hemorrhage (intracranial or extracranial hemorrhage). We used adjusted Cox regression with inverse probability of treatment weighting to determine associations between anticoagulation and study outcomes within 30 and 180 days. The main analysis used an as-treated crossover approach and only included outcomes occurring with the above treatments.
The study included 3636 patients (402 [11.1%] received exclusively anticoagulation and 2453 [67.5%] received exclusively antiplatelets). By day 180, there were 162 new ischemic strokes (4.4%) and 28 major hemorrhages (0.8%); 87.0% of ischemic strokes occurred by day 30. In adjusted Cox regression with inverse probability of treatment weighting, compared with antiplatelet therapy, anticoagulation was associated with a nonsignificantly lower risk of subsequent ischemic stroke by day 30 (adjusted hazard ratio [HR], 0.71 [95% CI, 0.45-1.12];
=0.145) and by day 180 (adjusted HR, 0.80 [95% CI, 0.28-2.24];
=0.670). Anticoagulation therapy was not associated with a higher risk of major hemorrhage by day 30 (adjusted HR, 1.39 [95% CI, 0.35-5.45];
=0.637) but was by day 180 (adjusted HR, 5.56 [95% CI, 1.53-20.13];
=0.009). In interaction analyses, patients with occlusive dissection had significantly lower ischemic stroke risk with anticoagulation (adjusted HR, 0.40 [95% CI, 0.18-0.88];
=0.009).
Our study does not rule out the benefit of anticoagulation in reducing ischemic stroke risk, particularly in patients with occlusive dissection. If anticoagulation is chosen, it seems reasonable to switch to antiplatelet therapy before 180 days to lower the risk of major bleeding. Large prospective studies are needed to validate our findings.
Details
- Title: Subtitle
- Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection: The STOP-CAD Study
- Creators
- Shadi Yaghi - Brown UniversityMalik Ghannam - University of Iowa, NeurologyLiqi Shu - Brown UniversityEdgar A Samaniego - University of Iowa, Iowa Neuroscience InstituteDaniel Mandel - University of MiamiChristopher R Leon Guerrero - George Washington UniversityNils Henninger - University of Massachusetts Chan Medical SchoolJayachandra Muppa - University of Massachusetts Chan Medical SchoolMuhammad Affan - University of MinnesotaOmair Ul Haq Lodhi - University of MinnesotaMirjam R Heldner - University of BernKateryna Antonenko - University of BernDavid Seiffge - University of BernMarcel Arnold - University Hospital of BernSetareh Salehi Omran - University of Colorado DenverRoss Crandall - Department of Neurology, University of Colorado, Denver (S.S.O., R. Crandall)Evan Lester - Department of Neurology, Weill Cornell Medicine, New York, NY (E.L.)Diego Lopez Mena - Instituto Nacional de Neurología y NeurocirugíaAntonio Arauz - Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez, Mexico City, Mexico (D.L.M., A. Arauz)Ahmad Nehme - Service de neurologie, Université Caen Normandie, CHU Caen Normandie, France (A.N., M.B., E.T.)Marion Boulanger - CyceronJoao Andre Sousa - Department of Neurology, Coimbra University, Portugal (J.A.S., J.S.-F., V.B.)Emmanuel Touze - Normandie UniversitéJoao Sargento-Freitas - Department of Neurology, Coimbra University, Portugal (J.A.S., J.S.-F., V.B.)Vasco Barata - Department of Neurology, Coimbra University, Portugal (J.A.S., J.S.-F., V.B.)Paulo Castro-Chaves - Universidade do PortoMaria Teresa Brito - Department of Internal Medicine, São João University Hospital, Porto, Portugal (P.C.-C., M.T.B.)Muhib Khan - Mayo ClinicDania MallickAaron Rothstein - University of PennsylvaniaOssama Khazaal - University of PennsylvaniaJosefin E Kaufmann - University Hospital of BaselStefan T Engelter - University Hospital of BaselChristopher Traenka - University Hospital of BaselDiana Aguiar de Sousa - Stroke Center, Centro Hospitalar Universitário Lisboa Central, and Institute of Anatomy, Faculdade de Medicina da Universidade de Lisboa, Portugal (D.A.d.S.)Mafalda Soares - University of LisbonSara Rosa - Department of Neuroradiology (S.R.), Centro Hospitalar Universitário Lisboa Central, Lisbon, PortugalLily W Zhou - University of British ColumbiaPreet Gandhi - University of British ColumbiaThalia S Field - University of British ColumbiaSteven Mancini - University of British ColumbiaIssa Metanis - Hadassah Medical CenterRonen R Leker - Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel (I.M., R.R.L.)Kelly Pan - Rhode Island HospitalVishnu Dantu - Brown UniversityKarl Baumgartner - Rhode Island HospitalTina Burton - Brown UniversityRegina Von Rennenberg - Department of Neurology, Charite Universitätsmedizin-Berlin und Center for Stroke Research, Germany (R.V.R., C.H.N.)Christian H Nolte - Charité - Universitätsmedizin BerlinRichard Choi - Department of Neurosciences, ChristianaCare, Newark, DE (R. Choi, J. MacDonald.)Jason MacDonald - Department of Neurosciences, ChristianaCare, Newark, DE (R. Choi, J. MacDonald.)Reza Bavarsad Shahripour - University of California San DiegoXiaofan Guo - Loma Linda UniversityMohammad Almajali - University of IowaSebastian Sanchez - University of IowaBastien Rioux - Department of Neurosciences, Université de Montréal, Canada (B.R., F.Z.-E., A.P.)Faycal Zine-Eddine - Department of Neurosciences, Université de Montréal, Canada (B.R., F.Z.-E., A.P.)Alexandre Poppe - Centre Hospitalier de l’Université de MontréalAna Catarina Fonseca - University of LisbonMaria Fortuna Baptista - Department of Neurology, Hospital de Santa Maria, Lisbon, Portugal (A.C.F., M.F.B., D.C.)Diana Cruz - Department of Neurology, Hospital de Santa Maria, Lisbon, Portugal (A.C.F., M.F.B., D.C.)Michele Romoli - Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy (M. Romoli, G.D.M., M.L.)Giovanna De Marco - Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy (M. Romoli, G.D.M., M.L.)Marco Longoni - Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy (M. Romoli, G.D.M., M.L.)Zafer Keser - Mayo ClinicKim Griffin - Mayo ClinicLindsey Kuohn - NYU Langone HealthJennifer Frontera - Department of Neurology, NYU Langone Health, New York (L.K., J.F.)Jordan Amar - Department of Neurology, Washington University, Saint Louis, MO (J.A., J.G.)James Giles - Yale UniversityMarialuisa Zedde - Neurology Unit, Stroke Unit (M.Z., I.G.), Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, ItalyRosario Pascarella - Neuroradiology Unit (R.P.), Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, ItalyIlaria Grisendi - Neurology Unit, Stroke Unit (M.Z., I.G.), Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, ItalyHipolito Nzwalo - Department of Internal Medicine, Centro Hospital Universitario do Algarve, Faro, Portugal (H.N.)David S Liebeskind - University of California, Los AngelesAmir Molaie - Department of Neurology, University of California at Los Angeles (D.S.L., A.M.)Annie Cavalier - Duke University School of MedicineWayneho Kam - Comprehensive Stroke Center, University of North Carolina Health Rex, Raleigh (W.K.)Brian Mac Grory - Duke University School of MedicineSami Al Kasab - Medical University of South CarolinaMohammad Anadani - Medical University of South CarolinaKimberly Kicielinski - Medical University of South CarolinaAli Eltatawy - University of CincinnatiLina Chervak - University of Cincinnati Medical CenterRoberto Chulluncuy-Rivas - University of CincinnatiYasmin Aziz - University of CincinnatiEkaterina Bakradze - University of Alabama at BirminghamThanh Lam Tran - Hackensack University Medical CenterMarc Rodrigo-Gisbert - Vall d'Hebron Hospital UniversitariManuel Requena - Vall d'Hebron Hospital UniversitariFaddi Saleh Velez - University of Oklahoma Health Sciences CenterJorge Ortiz Gracia - University of OklahomaVarsha Mudassani - Jefferson HealthcareAdam de Havenon - University of UtahVenugopalan Y Vishnu - Thomas Jefferson UniversitySridhara Yaddanapudi - Thomas Jefferson University HospitalLatasha Adams - Thomas Jefferson UniversityAbigail Browngoehl - Thomas Jefferson UniversityTamra Ranasinghe - Wake Forest UniversityRandy Dunston - Atrium Health Wake Forest BaptistZachary Lynch - Wake Forest UniversityMary Penckofer - Cooper Medical School of Rowan UniversityJames Siegler - Cooper University HospitalSilvia Mayer - Columbia UniversityJoshua Willey - Columbia UniversityAdeel Zubair - Yale School of MedicineYee Kuang Cheng - Department of Neurology, Yale New Haven Hospital, CT (A.d.H., A.Z., Y.K.C., R.S.)Richa Sharma - Department of Neurology, Yale New Haven Hospital, CT (A.d.H., A.Z., Y.K.C., R.S.)João Pedro Marto - Hospital de Egas MonizVítor Mendes Ferreira - Hospital de Egas MonizPiers Klein - Boston Medical CenterThanh N Nguyen - Boston Medical CenterSyed Daniyal Asad - Hartford HospitalZoha Sarwat - University of ConnecticutAnvesh Balabhadra - Department of Neurology, Hartford Hospital, CT (S.D.A., Z.S., A. Balabhadra, S.P.)Shivam Patel - University of ConnecticutThais Secchi - Hospital Moinhos de VentoSheila Martins - Hospital de Clínicas de Porto AlegreGabriel Mantovani - Hospital de Clínicas de Porto AlegreYoung Dae Kim - Department of Neurology, Yonsei University, Seoul, South Korea (Y.D.K.)Balaji Krishnaiah - University of Tennessee at KnoxvilleCheran Elangovan - Department of Neurology, University of Tennessee at Memphis (B.K., C.E.)Sivani Lingam - University of KansasAbid Quereshi - University Medical CenterSebastian Fridman - Department of Neurology, Western Ontario University, London, Canada (S.F., A. Alvarado)Alonso Alvarado - Department of Neurology, Western Ontario University, London, Canada (S.F., A. Alvarado)Farid Khasiyev - Saint Louis UniversityGuillermo Linares - Saint Louis UniversityMarina Mannino - Department of Neurology and Stroke Unit, AOOR Villa Sofia-V. Cervello, Palermo, Italy (M.M., V. Terruso)Valeria Terruso - Department of Neurology and Stroke Unit, AOOR Villa Sofia-V. Cervello, Palermo, Italy (M.M., V. Terruso)Sofia Vassilopoulou - National and Kapodistrian University of AthensVasilis Tentolouris - National and Kapodistrian University of AthensManuel Martinez-Marino - Autonomous University of CoahuilaVictor Carrasco Wall - Department of Neurology, Centro Médico Nacional Siglo XXI IMSS, México City, Mexico (M.M.M., V.C.W.)Fransisca Indraswari - Department of Neurology, The Miriam Hospital, Providence, RI (F.I., S.E.J.)Sleiman El Jamal - Brown UniversityShilin Liu - University of Science and Technology of ChinaMuhammad Alvi - West Virginia UniversityFarman Ali - West Virginia UniversityMohammed Sarvath - West Virginia UniversityRami Z Morsi - University of ChicagoTareq Kass-Hout - University of ChicagoFeina Shi - Zhejiang UniversityJinhua Zhang - Zhejiang UniversityDilraj Sokhi - Department of Neurology, Aga Khan University, Nairobi, Kenya (D. Sokhi, J. Said)Jamil Said - Department of Neurology, Aga Khan University, Nairobi, Kenya (D. Sokhi, J. Said)Alexis N Simpkins - Cedars-Sinai Medical CenterRoberto Gomez - Cedars-Sinai Medical CenterShayak Sen - Cedars-Sinai Medical CenterMohammad Ghani - Department of Neurology, University of Louisville, KY (M. Ghani, M.E.)Marwa Elnazeir - University of LouisvilleHan Xiao - University of California, Santa BarbaraNarendra Kala - Brown UniversityFarhan Khan - Brown UniversityChristoph Stretz - Brown UniversityNahid Mohammadzadeh - Brown UniversityEric Goldstein - Brown UniversityKaren Furie - Rhode Island Hospital
- Resource Type
- Journal article
- Publication Details
- Stroke (1970), Vol.55(4), pp.908-918
- DOI
- 10.1161/STROKEAHA.123.045731
- PMID
- 38335240
- NLM abbreviation
- Stroke
- ISSN
- 0039-2499
- eISSN
- 1524-4628
- Grant note
- K23 HL161426 / NHLBI NIH HHS
- Language
- English
- Date published
- 04/2024
- Academic Unit
- Neurology; Radiology; Iowa Neuroscience Institute; Neurosurgery
- Record Identifier
- 9984557839602771
Metrics
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